2017-04-27_REVISION - M1977057 - Laserfiche WebLink

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Sec.1 B.Effective date-This contract becomes effective as indicated below. 0 If this contract becomes effective on the date BLM signs the contract,BUM will chuck this boa. ❑ If this contract becomes effective only after certain conditions are met,BLrINt will check this boa,list the conditions below,and indicate the effective date. Sec. 19.appeal-You may appeal any decision that BLM makes in regard to this contract under Parts 4 and 1840 of'title 43 of the Code of Federal Regulations. The following parties have executed this contract as o)i PURCHASER THE UNITED STATES OF AMERICA 812W JWef ShViiD Cow! W_;1- XVC. By 'j_7..n o 7kV % J.LJR,/50,_7 (Individual or Finn Nam:) — Print Name of BLM Official) C040RAAO' c� l�sbs� �O 80'2 3'3 (Signatu a of BLM 011icial) (Phone Number—include area code) (Title) V Yho A � (Sign (Date) (Signature) Ifyou are a corporation,allix corporate seat here: Title 18 U.S.C.1001,makes it a crime for any person knowingly or willfully to mule to any department oragency orthe United States tiny false,fictitious or Iiaudulcm statements or mpnesentations as to any mattt:rAvithin its jurisdiction,subject to u fire ofup to$10,000 and imprisomment tip to 5 years. NOTICES The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)provide that you be furnished the following information in connection with information required by this application. AUTHORITY:30 U.S.C.601 el seq.;43 CFR Group 3600 PRINCIPAL PURPOSE:BLM uses this information to identify the parties entering into contracts for disposing of mineral materials. ROUTINE USES:BLM will truns(er information from the record or the record itself to appropriate Federal,State,local,or foreign agencies,when relevant to criminal,civil,or regulatory investigations or prosecutions. EFFECT OF NOT PROVIDING INFORMATION:If you do not provide this inrornmtion to BLM,we will not be able to process your application lbr a contract. The Paperwork Reduction Act requires us to inform you that: The BLM is collecting this information to process your application and effect a binding contract. The BLM will use this information to identify and communicme with applicants. You must respond to this request to get a benefit. You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a valid OMB control number. BURDEN HOURS STATEINIENT: Public reporting burden for this form is estimated to average about 1 hour per response,including the time for reviewing instructions,gathering and nhaintuining data,and completing and reviewing the form.You may submit comment.~regarding the burden estinhate or any other aspect orthis form to: U.S.Department of the Interior,Bureau ol'Land Management f 1004-0103),Bureau Information Collection Clearance Officer(WO-630), 1849 C Street,N.W.,Room 213.41-M,Washington,D,C.20240. (Form 3600-9,pagu 3)